Citation Nr: 1312274 Decision Date: 04/12/13 Archive Date: 04/19/13 DOCKET NO. 04-09 761 ) DATE ) ) On appeal from the Department of Veterans Affairs Regional Office in Montgomery, Alabama THE ISSUES 1. Entitlement to service connection for hypertension, to include as secondary to a service-connected disorder, or due to herbicide exposure in service. 2. Entitlement to service connection for impotency, to include as secondary to a service-connected disorder, or due to herbicide exposure in service. REPRESENTATION Appellant represented by: The American Legion ATTORNEY FOR THE BOARD Jeanne Schlegel, Counsel INTRODUCTION The Veteran had active service from August 1965 to June 1967. This matter comes before the Board of Veterans' Appeals (Board) on appeal from a decision of January 2003 of the Department of Veterans Affairs (VA) Regional Office (RO) in Jackson, Mississippi. Jurisdiction of the case was subsequently transferred to the Montgomery, Alabama, RO. The Veteran presented testimony at a Board video conference hearing held in October 2004. Subsequently, the Acting Veterans Law Judge who had conducted that hearing left the Board prior to issuing as disposition as to the claims on appeal. In June 2007, the Veteran was advised of this fact and notified that under the circumstances he could request another hearing; in a signed statement dated in June 2007 he elected not to request an additional hearing. This appeal was previously before the Board in May 2006, October 2007, November 2011, and September 2012 at which times it was remanded for further development. As will be discussed further herein, there has been substantial compliance with the remand directives, and the case has returned to the Board for appellate consideration. See also D'Aries v. Peake, 22 Vet. App. 97 (2008) (finding that only substantial compliance, rather than strict compliance, with the terms of a Board's remand directives is required). An April 2013 review of the Virtual VA paperless claims processing system reveals no additional documents pertinent to the present appeal. FINDINGS OF FACT 1. The Veteran had service in the Republic of Vietnam during the Vietnam era and therefore in-service exposure to herbicides including Agent Orange is presumed. 2. Hypertension is not among the enumerated conditions for which service connection may be established on a presumptive basis based on exposure to Agent Orange or other herbicide agents during service in Vietnam. 3. Hypertension was not manifested during service or during the first post-service year; it is not shown to be causally or etiologically related to service, including by virtue of exposure to herbicides presumptively sustained therein. 4. The preponderance of the evidence of record is against a finding that the Veteran's hypertension was caused, aggravated by, or otherwise related to, any service-connected disorder. 5. Impotency is not among the enumerated conditions for which service connection may be established on a presumptive basis based on exposure to Agent Orange or other herbicide agents during service in Vietnam. 6. Impotency was not manifested during service and it is not shown to be causally or etiologically related to service, including by virtue of exposure to herbicides presumptively sustained therein. 7. The preponderance of the evidence of record is against a finding that the Veteran's impotency was caused, aggravated by, or otherwise related to, any service-connected disorder CONCLUSIONS OF LAW 1. Hypertension was not incurred in or aggravated during active service, may not be presumed to have been so incurred, and is not secondarily related to a service connected condition. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). 2. Impotency was not incurred in or aggravated during active service, may not be presumed to have been so incurred, and is not secondarily related to a service connected condition. 38 U.S.C.A. §§ 1101, 1110, 1112, 1113, 1116, 5103, 5103A, 5107 (West 2002); 38 C.F.R. §§ 3.102, 3.159, 3.303, 3.304, 3.307, 3.309, 3.310 (2012). REASONS AND BASES FOR FINDINGS AND CONCLUSIONS Duty to Notify and Assist The Veterans Claims Assistance Act of 2000 (VCAA), 38 U.S.C.A. §§ 5100, 5102-5103A, 5106, 5107, 5126 (West 2002 & Supp. 2012), 38 C.F.R. §§ 3.102, 3.156(a), 3.159 and 3.326(a) (2012), requires VA to assist a claimant at the time that he or she files a claim for benefits. As part of this assistance, VA is required to notify claimants of what they must do to substantiate their claims. 38 U.S.C.A. § 5103(a); 38 C.F.R. § 3.159(b)(1). Specifically, VA must inform the claimant of any information and evidence not of record (1) that is necessary to substantiate the claim; (2) that the claimant is to provide; and (3) that VA will attempt to obtain. See Beverly v. Nicholson, 19 Vet. App. 394, 403 (2005) (outlining VCAA notice requirements). The RO informed the Veteran of VA's duty to assist him in the development of evidence pertinent to his service connection claims in no less than 8 letters dated between October 2002 and October 2012, wherein the Veteran was advised of the provisions relating to the VCAA. The Veteran was advised that VA would assist him with obtaining relevant records from any Federal agency, which may include medical records from the military, from VA hospitals (including private facilities where VA authorized treatment), or from the Social Security Administration. With respect to private treatment records, the letter informed the Veteran that VA would make reasonable efforts to obtain private or non-Federal medical records, to include records from State or local governments, private doctors and hospitals, or current or former employers. Furthermore, the VA included copies of VA Form 21-4142, Authorization and Consent to Release Information, which the Veteran could complete to release private medical records to the VA. The Board further observes that the United States Court of Appeals for Veterans Claims (Court) issued a decision in the consolidated appeal of Dingess/Hartman v. Nicholson, 19 Vet. App. 473 (2006), which held that the VCAA notice requirements of 38 U.S.C.A. § 5103(a) and 38 C.F.R. § 3.159(b) apply to all five elements of a service connection claim. Those five elements include: (1) Veteran status; (2) existence of a disability; (3) a connection between the Veteran's service and the disability; (4) degree of disability; and (5) effective date of the disability. The Veteran was provided with notice of the type of evidence necessary to establish a disability rating or effective date as was discussed in the Dingess case in several letters dating from May 2006, forward, after the initial adjudication of the claims in January 2003. Thereafter, the RO adjudicated the claims in Supplemental SOCs issued in 2006, 2009, 2011, 2012, and 2013. See Prickett v. Nicholson, 20 Vet. App. 370, 376 (2006) (the issuance of fully compliant notification followed by readjudication of the claim, such as an Statement of the Case or Supplemental Statement of the Case, is sufficient to cure a timing defect). The Board also finds that all of the relevant facts have been properly developed, and that all available evidence necessary for an equitable resolution of the issues on appeal has been obtained. The Veteran's service treatment records (STRs) and post-service treatment records, including private medical reports and VA records, have been obtained and associated with the file. In addition lay statements have also been added to the file along with contentions and arguments provided by the Veteran. VA's duty to assist also includes obtaining an examination and medical opinion when necessary to make an adequate determination. See Duenas v. Principi, 18 Vet. App. 512 (2004). During the appeal period, VA examinations dated from 2002 to 2012 were associated with the file, addressing both of the service connection claims in appellate status, and all of the theories of entitlement. The Veteran has not maintained that any of these examinations were inadequate. See Sickels v. Shinseki, 643 F.3d 1362 (Fed. Cir. 2011), (in the absence of a challenge to the adequacy of the examination, the Board is not required to explicitly explain why each medical opinion is adequate). Accordingly, the Board finds that VA has complied, to the extent required, with the duty-to-assist requirements found at 38 U.S.C.A. § 5103A and 38 C.F.R. § 3.159(c)-(e). Service Connection Claims Generally, in order to prevail on the issue of service connection, there must be evidence of a current disability; medical evidence, or in certain circumstances, lay evidence of in-service occurrence or aggravation of a disease or injury; and evidence of a nexus between an in-service injury or disease and the current disability. See Hickson v. West, 12 Vet. App. 247, 253 (1999). Service connection may be granted if the evidence demonstrates that a current disability resulted from an injury or disease incurred or aggravated in active military service. 38 U.S.C.A. § 1110; 38 C.F.R. § 3.303(a). If there is no showing of a resulting chronic condition during service, then a showing of continuity of symptomatology after service is required to support a finding of chronicity. 38 C.F.R. § 3.303(b). Service connection may also be granted for any injury or disease diagnosed after discharge, when all the evidence, including that pertinent to service, establishes that the disease or injury was incurred in service. 38 C.F.R. § 3.303(d). Service connection shall be granted to a Veteran if the Veteran served 90 days or more during a war period or after December 31, 1946 or had peacetime service on or after January 1, 1947, and conditions including and hypertension, although not otherwise established as incurred in or aggravated by service, are manifested to a compensable degree within one year following the requisite service. 38 C.F.R. §§ 3.307, 3.309 (2012). The Board must assess the credibility and weight of all the evidence, including the medical evidence, to determine its probative value, accounting for evidence which it finds to be persuasive or unpersuasive, and providing reasons for rejecting any evidence favorable to the claimant. See Masors v. Derwinski, 2 Vet. App. 181 (1992); Wilson v. Derwinski, 2 Vet. App. 614, 618 (1992); Hatlestad v. Derwinski, 1 Vet. App. 164 (1991). Equal weight is not accorded to each piece of evidence contained in the record; every item of evidence does not have the same probative value. It is VA's defined and consistently applied policy to administer the law under a broad interpretation, consistent, however, with the facts shown in every case. When, after careful consideration of all procurable and assembled data, a reasonable doubt arises regarding service origin, the degree of disability, or any other point, such doubt will be resolved in favor of the claimant. By reasonable doubt it is meant that an approximate balance of positive and negative evidence exists which does not satisfactorily prove or disprove the claim. It is a substantial doubt and one within the range of probability as distinguished from pure speculation or remote possibility. See 38 U.S.C.A. § 5107(b) (West 2002); 38 C.F.R. § 3.102 (2012). The question is whether the evidence supports the claim or is in relative equipoise, with the claimant prevailing in either event, or whether a fair preponderance of the evidence is against the claim, in which event the claim must be denied. See Gilbert v. Derwinski, 1 Vet. App. 49, 53-54 (1990). I. Hypertension The Veteran filed an original service connection claim for hypertension in September 2002, claiming that this condition had its onset in 1985. The STRs include a August 1965 enlistment examination report which revealed that clinical evaluation of the lungs, chest and heart was normal and that a blood pressure reading of 120/86 was made. A discharge examination report of June 1967 also reflected that clinical evaluation of the lungs, chest and heart was normal and showed that a blood pressure reading of 110/65 was made. The records are entirely negative for any complaints, findings or diagnosis relating to hypertension. Private medical records dated in June 1995 indicate that the Veteran was seen for a follow up for high blood pressure. Records dated in 1996 reflect that he continued to be followed for high blood pressure. Controlled high blood pressure was noted in a 1997 record. An August 1999 record shows a diagnosis of hypertension. Private medical records of October and November 2000 reflect that the Veteran was hospitalized due to symptoms of chest pain. Diagnoses of chest pain due to atherosclerotic heart disease, hypertension, and hyperlipidemia were made. Records of November 2000 reflect that multi-vessel atherosclerotic coronary artery disease and normal left ventricular function were diagnosed, due to which the Veteran underwent left heart catheterization, selective coronary angiography, and left ventriculogram. The file contains a September 2002 private medical statement of Dr. S.V.I. to the effect that there was a possibility that some of the Veteran's medical problems, including hypertension, may be associated with exposure to Agent Orange sustained during his service in Vietnam. A VA examination was conducted in November 2002. The Veteran reported that he believed he had symptoms of hypertension in service, although it was not diagnosed until 1978 or 1979. He mentioned that he did not recall ever being told of having elevated blood pressure during service. A blood pressure reading of 158/90 was made and hypertension was diagnosed. The Veteran presented testimony during a Board video conference hearing held in October 2004. He mentioned that hypertension had initially been diagnosed in the late 1970's. He was not sure whether he had problems with hypertension prior to 1978, but indicated that he was under a great deal of stress while in Vietnam, suggesting that hypertension was directly related to service or possibly related to psychiatric symptoms/a psychiatric condition (pgs. 11-12). The file contains a private medical report of Dr. T.R.P. dated in October 2007. In that report it was noted that the Veteran had developed hypertension, which he attributed to excessive anxiety associated with his PTSD. Private medical records dated from 2006 to 2009 reflect that the Veteran continued to be followed for diagnosed hypertension. In an undated medical statement, received in September 2009, Dr. S.N.M. indicated that due to PTSD, the Veteran had been experiencing increased blood pressure at times. Pursuant to a March 2010 Board decision, service connection was established for anxiety disorder, for which a 30 percent evaluation was granted, effective from September 2002. A VA hypertension examination was conducted in July 2010 and the claims folder was reviewed. Hypertension, onset in the 1980's, was noted. Essential hypertension was diagnosed. The examiner opined that it was less likely as not that hypertension was caused by or the result of service, herbicide exposure sustained therein, or a service-connected condition. The examiner explained that the Veteran clearly had essential hypertension and noted that there was no objective data to correlate the onset and pattern of service-connected psychiatric symptoms with his control of hypertension. The examiner stated that these are independent conditions based on review of the blood pressure readings and the notes for the symptoms/treatment of the psychiatric condition. In a VA addendum provided in July 2011, the VA examiner clarified that hypertension was not due to service or to the service-connected psychiatric condition. It was explained that the onset of the hypertension was after service and that there was a lack of objective evidence to correlate the psychiatric symptoms with the onset of hypertension. It was also opined that both erectile dysfunction and hypertension were not due to coronary artery disease (currently service-connected), as both conditions preceded coronary artery disease (CAD) by many years. In a September 2011 rating action, service connection was established for CAD with angina for which a 10 percent evaluation was granted, effective from September 2002; and a 60 percent evaluation assigned, effective from July 2010. In November 2011, a second VA addendum opinion was provided. At the outset, it was noted that prior to the onset of CAD and being on treatment for mental health disorder, the Veteran was on mild amounts of hypertensive treatment for control of his blood pressure. It was also mentioned that erectile dysfunction was already present and that the Veteran was not really getting any results with treatment. The examiner observed that there was no evidence of an increase in manifestations of hypertension and erectile dysfunction beyond the natural progression of the diseases. The examiner opined that erectile dysfunction and hypertension were less likely than not permanently aggravated by service-connected CAD and stress/anxiety disorder. The following reasons supporting that conclusion were given: (1) hypertension and erectile dysfunction were present prior to CAD and the start of treatment for anxiety; (2) both of these conditions had a baseline which was well documented from the records in the claims folders; (3) the conditions had only mildly progressed since that time based on objective review of the claims folders and VA treatment records. The examiner further explained that this increase was completely consistent with the normal progression of the diseases and that there was no objective evidence indicating an acceleration of the conditions/symptoms beyond the natural progression. The examiner concluded that the blood pressure readings and amounts of treatment were still mild and that the effects of erectile dysfunction were still minimal. Pursuant to a September 2012 Board remand, another VA opinion was requested. In October 2012, a third addendum was provided and the examiner specifically acknowledged having considered the report of Dr. S.N.M; VA examination reports of 2010 and 2011; as well as 2007 treatment notes. Based upon such review, the VA examiner, opined that erectile dysfunction and hypertension were less likely than not aggravated by service-connected heart and anxiety disorders. The examiner explained that the baseline patterns of these conditions had been reviewed, including the symptoms and treatment. It was further observed that erectile dysfunction and hypertension preceded CAD and anxiety disorder. The examiner noted that the objective evidence reviewed regarding the aggravation issue included the number of treatments and dosage amounts used to control the conditions, as well as review of mental health notes and blood pressure readings. It was stated that based on this review, there had not been any significant increase in either erectile dysfunction or hypertension since the onset of CAD or anxiety disorder. The examiner further opined that erectile dysfunction and hypertension were not related to or caused by treatment for service-connected anxiety or a heart condition. The examiner explained that erectile dysfunction and hypertension preceded treatment for these conditions and that due to this timing, it was not possible for the treatment to be a cause. Analysis The Veteran contends that his claimed hypertension is linked to exposure to herbicides including Agent Orange during service, warranting service connection on a presumptive basis. In the alternative, the condition is claimed on the bases of direct and secondary service-connection. The medical criteria relevant to rendering a diagnosis of hypertension for VA purposes is set out in VA Training Letter 00-07 (July 17, 2000), which states that hypertension is present if the diastolic blood pressure is 90 mm Hg or more or the systolic pressure is 140 mm Hg or more, or if both are present. In isolated systolic hypertension, the systolic pressure is 140 mm Hg or more, but the diastolic pressure is less than 90 mm Hg. Indisputably, the record contains medical evidence of currently diagnosed hypertension, as shown by VA examination reports of 2002 and 2010. The remaining question is whether or not currently manifested hypertension was incurred during or as a result of the Veteran's active military service, presumptively or otherwise, or is secondarily related to a service-connected disorder by virtue of causation or aggravation. As an initial matter, there is no indication of in-service incurrence of hypertension. The STRs are silent for any indication of treatment for hypertension, clinical diagnoses of hypertension, or other clinical indications such as high blood pressure. At the time of his separation examination, a normal blood pressure reading of 110/65 was made and the lungs, chest, and heart were described as normal. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (Observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). The fact that the STRs and separation examination report failed to include a diagnosis or reference to hypertension weighs heavily against the claim based on the theory of direct service incurrence. The record also fails to show that hypertension manifested to a degree of 10 percent by June 1968 (within the first year following his active duty service discharge, in June 1967), nor does the Veteran specifically maintain that it manifested during this time frame. A chronic disease need not be diagnosed during the presumptive period under 38 C.F.R. § 3.307(c), but if not, there must then be shown by acceptable medical or lay evidence, characteristic manifestations of the disease to the required degree, followed without unreasonable time lapse by definite diagnosis. Caldwell v. Derwinski, 1 Vet. App. 466, 469 (1991). No such evidence has been presented in this case. In fact, lay and clinical evidence reflects that hypertension was initially identified/diagnosed no early than the late 1970's or early 1980's, at least a decade after the Veteran's discharge from service. Accordingly, service connection on a presumptive basis is not established under 38 C.F.R. §§ 3.307, 3.309. A Veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). This is the third part of the Hickson analysis. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Hickson elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Brown, 10 Vet. App. 488, 495- 97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). With respect to the theory of direct service incurrence, the evidence of record does not establish that the Veteran currently has hypertension which is etiologically or causally associated with service. Specifically, there has been no medical evidence or opinion provided which causally relates the Veteran's period of military service to his currently diagnosed hypertension. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 Fed. Cir. 1998). In fact, the file contains VA medical opinions of July 2010 and July 2011 to the effect that was less likely than not incurred in or caused by service. These opinions were based on review of the Veteran' s lay history, to include service and post-service records and examination results, as well as on specialized clinical experience and knowledge. As such, this evidence is considered both competent and highly probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Therefore, Board finds no adequate basis to reject these competent medical opinions based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In addition, the Veteran has not provided any competent medical evidence to rebut these opinions or to otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Further, lay information and clinical records reflect that the initial diagnosis of hypertension was made at the earliest more than a decade after the Veteran's discharge from service. Evidence of a prolonged period without medical complaint and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, there is no evidence of a chronic disability (hypertension) during the Veteran's period of active service, or of continuity of symptomatology after his period of active service. Hence, continuity and chronicity of symptoms of hypertension is not established in this case. The Board has also considered whether the Veteran's hypertension could be due to exposure to Agent Orange. Applicable regulations provide that a Veteran who served on active duty in Vietnam during the Vietnam era is presumed to have been exposed to Agent Orange or similar herbicide. 38 C.F.R. § 3.307(a)(1)(6)(iii). The Veteran's DD 214 and service personnel records reflect that he served with the United States Army from August 1965 to June 1967, to include service in Vietnam. He is therefore presumed to have been exposed to herbicides during service, including Agent Orange. The specific statute pertaining to claimed Agent Orange exposure is 38 U.S.C.A. § 1116. Regulations issued pursuant thereto stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. The diseases that are entitled to presumptive service connection based on herbicide exposure are listed in 38 C.F.R. § 3.309(e). This regulation was amended effective August 31, 2010, to add, in relevant part, ischemic heart disease, to include manifested by atherosclerotic cardiovascular disease including coronary artery disease (including coronary spasm) and coronary bypass surgery; and stable, unstable and Prinzmetal's angina. 75 Fed. Reg. 53202 (August 31, 2010). However, for purposes of the aforementioned section, the term ischemic heart disease does not include hypertension, or any other condition that does not qualify within the generally accepted medical definition of ischemic heart disease. 38 C.F.R. § 3.309(e), Note 3 (effective August 31, 2010). Accordingly, the criteria for presumptive service connection for hypertension on the basis of herbicide exposure have not been satisfied. In addition to the presumptive regulations, a Veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). The file contains two medical opinions addressing the link between hypertension initially diagnosed at least a decade after service and herbicide exposure, sustained on a presumptive basis therein. In this regard, the record contains a July 2010 VA opinion to the effect that it was less likely as not that hypertension was caused by or the result of service, to include herbicide exposure sustained therein, based on the remoteness of the initial diagnosis. In contrast, in 2002, Dr. S.V.I. opined to the effect that there was a possibility that some of the Veteran's medical problems, including hypertension, may be associated with exposure to Agent Orange during his service in Vietnam. Of these two opinions, the VA opinions, which was based on a full review of the Veteran's lay and medical history is found to be of greater probative value. With respect to the 2002 opinion, medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The Board observes that an award of service connection may not be based on resort to speculation or remote possibility. See 38 C.F.R. §§ 3.102. Accordingly, the 2002 opinion is found to be of far less probative value as compared to the VA opinion provided in 2010. The Veteran has also maintained that hypertension may be secondary to a service connected anxiety disorder or to CAD. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2008); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). In this case, the file contains no less than 4 VA opinions indicating that hypertension was less likely than not caused or aggravated by a service-connected anxiety disorder or CAD. The reasons supporting those opinions are detailed above and reflect review of the entirety of the history of both the claimed conditions, the service-connected conditions, and the treatment and progression of both. Hence, these opinions are collectively considered to be or great probative value. In this regard, among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). In contrast, the file contains a sole opinion of Dr. S.N.M. to the effect that due to PTSD, the Veteran had been experiencing increased blood pressure at times. As a technical matter, service connection is not in effect for PTSD. Further, the mere fact that some increased blood pressure readings were noted and linked to a psychiatric condition, is not an indicator of either causation nor chronic aggravation, and no such opinion was actually provided by Dr. S.N.M. Moreover, this opinion failed to account for or discuss the fact that hypertension well preceded the diagnosis and treatment of a psychiatric disorder and did not identify any baseline manifestations of hypertension; issues which were both addressed by the VA opinions provided between 2010 and 2012. As such, the opinion of Dr. S.N.M. is of much lower probative value than the 4 VA opinions provided from 2010 to 2012. To the extent that the Veteran himself asserts he suffers from a hypertension as a result service, to include herbicide exposure sustained in service, the Board does not question the Veteran's sincerity in his belief that this condition is etiologically related to such a cause. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, diagnosing hypertension and providing an opinion as to its etiology falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for hypertension. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. II. Impotency The Veteran filed an original service connection claim for impotency in September 2002, claiming that this condition had its onset in 1983. The STRs are negative for any indications or a diagnosis of impotency. Private medical records include an August 1999 entry indicating that the Veteran had intermittent impairment of erection quality and duration which he attributed to Norvasc, but did not wish to change this medication regimen. A September 2000 record reflected that he continued to have erectile dysfunction manifested by premature loss of erection prior to ejaculation. Erectile dysfunction was diagnosed. The file contains a September 2002 private medical statement of Dr. S.V.I. to the effect that there was a possibility that some of the Veteran's medical problems, including impotency, may be associated with exposure to Agent Orange sustained during his service in Vietnam. A VA examination was conducted in November 2002. The Veteran reported having served in Vietnam and being exposed to Agent Orange. He gave a history of impotency since 1979, and stated that vaginal penetration and ejaculation were not possible. It was noted that he was not a diabetic, but was hypertensive. Impotence of undetermined etiology was diagnosed. A general medical examination report of November 2002 mentioned that he was intolerant of Viagra and unable to take it due to heart disease. In a statement provided in March 2004, the Veteran maintained that his impotency was due to medications being taken for PTSD and/or hypertension. The Veteran presented testimony during a Board video conference hearing held in October 2004. He stated that he had experienced long-term problems with impotency, which he believed was related to service related stress, hypertension, or psychiatric symptoms/a psychiatric condition (pgs. 12-13). Pursuant to a March 2010 Board decision, service connection was established for anxiety disorder, for which a 30 percent evaluation was granted, effective from September 2002. A VA examination was conducted in July 2010 and the claims folder was reviewed. Erectile dysfunction onset in the 1980's was noted. The Veteran reported that the timing of this was just after starting hypertension treatment, continuing since then. Erectile dysfunction most likely related to medication was noted. The examiner opined that it was less likely as not that erectile dysfunction was caused by or the result of service, herbicide exposure sustained therein, or a service-connected condition. The examiner explained that the erectile dysfunction clearly correlated with the onset of hypertension based on review of the data and the Veteran's lay history. The examiner stated that the hypertension treatment that the Veteran was on was well known to cause the side effects of sexual dysfunction and erectile dysfunction. In an addendum provided in July 2011, the VA examiner clarified that hypertension was not due to service or to the service-connected psychiatric condition. It was explained that the onset of the hypertension was after service and that there was a lack of objective evidence to correlate the psychiatric symptoms with the onset of hypertension. The examiner further stated that erectile dysfunction started soon after the hypertension, due to the effects of hypertension treatment. The VA examiner clarified that erectile dysfunction was not due to service or to the service-connected psychiatric condition, and noted that the correlation between erectile dysfunction and hypertension was solid. It was also opined that both erectile dysfunction and hypertension were not due to CAD (currently service-connected), as both conditions preceded CAD by many years. Service connection for CAD with angina was established in a September 2011 rating action. In November 2011, a second VA addendum opinion was provided. At the outset, it was noted that prior to the onset of CAD and being on treatment for mental health disorder, the Veteran was on mild amounts of hypertensive treatment for control of his blood pressure. It was also mentioned that erectile dysfunction was already present and that the Veteran was not really getting any results with treatment. The examiner observed that there was no evidence of an increase in manifestations of hypertension and erectile dysfunction beyond the natural progression of the disease. The examiner opined that erectile dysfunction and hypertension were less likely than not permanently aggravated by service-connected CAD and stress/anxiety disorder. The following reasons supporting that conclusion were given: (1) hypertension and erectile dysfunction were present prior to CAD and being started on treatment for anxiety; (2) both of these conditions had a baseline which was well documented from the records in the claims folders; (3) the conditions had only mildly progressed since that time based on objective review of the claims folders and VA treatment records. The examiner further explained that this increase was completely consistent with the normal progression of the diseases and that there was no objective evidence indicating an acceleration of the conditions/symptoms beyond the natural progression. The examiner concluded that the blood pressure readings and amounts of treatment were still mild and that the effects of erectile dysfunction were still minimal. Pursuant to a September 2012 Board remand, another VA opinion was requested. In October 2012, a third addendum was provided and the examiner specifically acknowledged having considered the report of Dr. S.N.M; VA examination reports of 2010 and 2011; as well as 2007 treatment notes. Based upon such review, the VA examiner opined that erectile dysfunction and hypertension were less likely than not aggravated by service-connected heart and anxiety disorders. The examiner explained that the baseline patterns of these conditions had been reviewed, including the symptoms and treatment. It was further observed that erectile dysfunction and hypertension preceded CAD and anxiety disorder. The examiner noted that the objective evidence reviewed regarding the aggravation issue included the number of treatments and dosage amounts used to control the conditions, as well as review of mental health notes and blood pressure readings. It was stated that based on this review, there had not been any significant increase in either erectile dysfunction or hypertension since the onset of CAD or anxiety disorder. The examiner further opined that erectile dysfunction and hypertension were not related to or caused by treatment for service-connected anxiety or a heart condition. The examiner explained that erectile dysfunction and hypertension preceded treatment for these conditions and that due to this timing, it was not possible for the treatment to be a cause. Analysis The Veteran contends that his claimed erectile dysfunction is linked to exposure to herbicides including Agent Orange during service, warranting service connection on a presumptive basis. In the alternative, the condition is claimed on the bases of direct and secondary service-connection. Indisputably, the record contains medical evidence of currently diagnosed erectile dysfunction, as shown by VA examination reports of 2002 and 2010. The remaining question is whether or not currently manifested impotency was incurred during or as a result of the Veteran's active military service, or is secondarily related to a service-connected disorder by virtue of causation or aggravation. As an initial matter, there is no indication of in-service incurrence of impotency. The STRs and separation examination report are silent for any indication of complaints, treatment or a diagnosis of erectile dysfunction. See Rucker v. Brown, 10 Vet. App. 67, 73 (1997) (Observing that although formal rules of evidence do not apply before the Board, recourse to the Federal Rules of Evidence may be appropriate if it assists in the articulation of the reasons for the Board's decision). The fact that the STRs and separation examination report failed to include a diagnosis or reference to impotency weighs heavily against the claim based on the theory of direct service incurrence. A Veteran seeking disability benefits must establish not only the existence of a disability, but also an etiological connection between his military service and the disability. Boyer v. West, 210 F.3d 1351, 1353 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000). This is the third part of the Hickson analysis. Under 38 C.F.R. § 3.303(b), an alternative method of establishing the second and third Hickson elements is through a demonstration of continuity of symptomatology. Barr v. Nicholson, 21 Vet. App. 303 (2007); see Savage v. Brown, 10 Vet. App. 488, 495- 97 (1997); see also Clyburn v. West, 12 Vet. App. 296, 302 (1999). Continuity of symptomatology may be established if a claimant can demonstrate (1) that a condition was "noted" during service; (2) evidence of post-service continuity of the same symptomatology; and (3) medical or, in certain circumstances, lay evidence of a nexus between the present disability and the post-service symptomatology. Savage, 10 Vet. App. at 495-96; see Hickson, 12 Vet. App. at 253 (lay evidence of in-service incurrence sufficient in some circumstances for purposes of establishing service connection); 38 C.F.R. § 3.303(b). With respect to the theory of direct service incurrence, the evidence of record does not establish that the Veteran currently has impotency which is etiologically or causally associated with service. Specifically, there has been no medical evidence or opinion provided which causally relates the Veteran's period of military service to his currently diagnosed impotency. See Watson v. Brown, 4 Vet. App. 309, 314 (1993) ("A determination of service connection requires a finding of the existence of a current disability and a determination of a relationship between that disability and an injury or disease incurred in service."). See, too, Maggitt v. West, 202 F.3d 1370, 1375 (Fed. Cir. 2000); D'Amico v. West, 209 F.3d 1322, 1326 (Fed. Cir. 2000); Hibbard v. West, 13 Vet. App. 546, 548 (2000); and Collaro v. West, 136 F.3d 1304, 1308 Fed. Cir. 1998). In fact, the file contains VA medical opinions of July 2010 and July 2011 to the effect that erectile dysfunction was less likely than not incurred in or caused by service. These opinions were based on review of the Veteran' s lay history, to include service and post-service records and examination results, as well as on specialized clinical experience and knowledge, and this evidence is considered both competent and highly probative. See Prejean v. West, 13 Vet. App. 444, 448-9 (2000). Therefore, Board finds no adequate basis to reject these competent medical opinions based on a lack of credibility or probative value. Madden v. Gober, 125 F.3d 1477, 1481 (Fed. Cir. 1997); Evans v. West, 12 Vet. App. 22, 26 (1998). In addition, the Veteran has not provided any competent medical evidence to rebut these opinions or to otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). Further, lay information and clinical records reflect that the initial diagnosis of impotency was made at the earliest more than a decade after the Veteran's discharge from service, approximately sometime between 1979 and 1983, according to various accounts provided by the Veteran. Evidence of a prolonged period without medical complaint and the amount of time that elapsed since military service, can be considered as evidence against the claim. Maxson v. Gober, 230 F.3d 1330, 1333 (Fed. Cir. 2000). Moreover, there is no evidence of a chronic disability, impotency during the Veteran's period of active service, or of continuity of symptomatology after his period of active service. Hence, continuity and chronicity of symptoms of impotency is not established in this case. The Board has also considered whether the Veteran's impotency could be due to exposure to Agent Orange. Applicable regulations provide that a Veteran who served on active duty in Vietnam during the Vietnam era is presumed to have been exposed to Agent Orange or similar herbicide. 38 C.F.R. § 3.307(a)(1)(6)(iii). The Veteran's DD 214 and service personnel records reflect that he served with the United States Army from August 1965 to June 1967, to include service in Vietnam. He is therefore presumed to have been exposed to herbicides during service, including Agent Orange. The specific statute pertaining to claimed Agent Orange exposure is 38 U.S.C.A. § 1116. Regulations issued pursuant thereto stipulate the diseases for which service connection may be presumed due to an association with exposure to herbicide agents. The diseases that are entitled to presumptive service connection based on herbicide exposure are listed in 38 C.F.R. § 3.309(e), and do not include impotency or erectile dysfunction. Accordingly, the criteria for presumptive service connection on the basis of herbicide exposure have not been satisfied. In addition to the presumptive regulations, a Veteran may establish service connection based on exposure to Agent Orange with proof of actual direct causation. See Stefl v. Nicholson, 21 Vet. App. 120 (2007) (holding that the availability of presumptive service connection for some conditions based on exposure to Agent Orange does not preclude direct service connection for other conditions based on exposure to Agent Orange); Combee v. Brown, 34 F.3d 1039 (Fed. Cir. 1994); Brock v. Brown, 10 Vet. App. 155 (1997). The file contains two medical opinions addressing the link between impotency, initially diagnosed at least a decade after service, and herbicide exposure sustained on a presumptive basis therein. In this regard, the record contains a July 2010 VA opinion to the effect that it was less likely as not that erectile dysfunction was caused by or the result of service, to include herbicide exposure sustained therein, based on the remoteness of the initial diagnosis. In contrast, in 2002, Dr. S.V.I. opined to the effect that there was a possibility that some of the Veteran's medical problems, including impotency, may be associated with exposure to Agent Orange during his service in Vietnam. Of these two opinions the VA opinion, which was based on a full review of the Veteran's lay and medical history is found to be of greater probative value. With respect to the 2002 opinion, medical evidence that is speculative, general, or inconclusive in nature cannot support a claim. See Obert v. Brown, 5 Vet. App. 30, 33 (1993); see also Beausoleil v. Brown, 8 Vet. App. 459, 463 (1996); Libertine v. Brown, 9 Vet. App. 521, 523 (1996). The Board observes that an award of service connection may not be based on resort to speculation or remote possibility. See 38 C.F.R. §§ 3.102. Accordingly, the 2002 opinion is found to be of far less probative value as compared to the VA opinion provided in 2010. The Veteran has also maintained that impotency may be secondary to a service connected anxiety disorder or to CAD. Service connection may be established on a secondary basis for a disability that is proximately due to or the result of a service-connected disease or injury. 38 C.F.R. § 3.310(a) (2012). Establishing service connection on a secondary basis requires evidence sufficient to show (1) that a current disability exists and (2) that the current disability was either (a) caused by or (b) aggravated by a service-connected disability. 38 C.F.R. § 3.310(a) (2008); Allen v. Brown, 7 Vet. App. 439 (1995) (en banc), reconciling, Leopoldo v. Brown, 4 Vet. App. 216 (1993), and Tobin v. Derwinski, 2 Vet. App. 34 (1991). In this case, the file contains no less than 4 VA opinions indicating that erectile dysfunction was less likely than not caused or aggravated by a service-connected anxiety disorder or CAD. The reasons supporting those opinions are detailed above and reflect review of the entirety of the history of both the claimed conditions, the service-connected condition, and the treatment and progression of both. Significantly, the Veteran's erectile dysfunction was linked to treatment for his hypertension. Specifically, in a July 2010 VA opinion, the examiner stated that the hypertension treatment that the Veteran was on was well known to cause the side effects of sexual dysfunction and erectile dysfunction. Hence, these opinions are collectively considered to be or great probative value. In this regard, among the factors for assessing the probative value of a medical opinion are the physician's access to the claims file and the thoroughness and detail of the opinion. See Prejean v. West, 13 Vet. App. 444, 448-49 (2000). Further, the Veteran has not provided any competent medical evidence to rebut these opinions or to otherwise diminish their probative weight. See Wray v. Brown, 7 Vet. App. 488, 492-93 (1995). To the extent that the Veteran himself asserts he suffers from impotency as a result service, to include herbicide exposure sustained in service, the Board does not question the Veteran's sincerity in his belief that this condition is etiologically related to such a cause. Although lay persons are competent to provide opinions on some medical issues, see Kahana v. Shinseki, 24 Vet. App. 428, 435 (2011), as to the specific issue in this case, diagnosing impotency and providing an opinion as to its etiology falls outside the realm of common knowledge of a lay person. See Jandreau v. Nicholson, 492 F.3d 1372, 1377 n.4 (Fed. Cir. 2007) (lay persons not competent to diagnose cancer)." Accordingly, the Board finds that the preponderance of the evidence is against the Veteran's service connection claim for impotency. Although the Veteran is entitled to the benefit of the doubt where the evidence is in approximate balance, the benefit of the doubt doctrine is inapplicable where, as here, the preponderance of the evidence is against the claim. See generally Gilbert v. Derwinski, 1 Vet. App. 49 (1990); Ortiz v. Principi, 274 F. 3d 1361 (Fed. Cir. 2001). The benefit sought on appeal is therefore denied. ORDER Entitlement to service connection for hypertension is denied. Entitlement to service connection for impotency is denied. ____________________________________________ MARJORIE A. AUER Veterans Law Judge, Board of Veterans' Appeals Department of Veterans Affairs